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Objective: Unintended pregnancies are common among women living with HIV, but there are no data on their long-term impact on treatment outcomes. In a cohort of women initiating antiretroviral therapy (ART) during pregnancy, we examined the association between the intendedness of the current pregnancy, measured antenatally, and elevated viral load up to 5 years postpartum., Design: Prospective study with enrolment at entry into antenatal care and follow-up at study visits separate from routine care., Methods: At enrolment women completed the London Measure of Unplanned Pregnancy. Mixed effects models examined the impact of the intendedness of the pregnancy (planned versus each of unplanned or ambivalent, respectively) on viral load 50 or more copies/ml across postpartum study visits., Results: Overall, 459 women were followed for a median of 43 months postpartum, contributing 2535 viral load measures (median per woman: 6). Ambivalent and unplanned pregnancy were commonly reported (20 and 60%, respectively), and the proportion of women with elevated viral load increased over time (16% at 6 weeks to 43% by 36-60 months postpartum). Compared with those reporting a planned pregnancy, elevated viral load was more common among women reporting an unplanned pregnancy (odds ratio: 2.87; 95% confidence interval: 1.46-5.64), with a trend towards a higher odds among those reporting ambivalence (odds ratio: 2.19; 95% confidence interval: 0.97-4.82); associations persisted after adjustment for a wide range of demographic, clinical and psychosocial factors., Conclusion: These novel data suggest that unplanned pregnancy may be a prevalent and persistent predictor of poor ART outcomes among women initiating ART during pregnancy.

HIV-status disclosure may improve psychosocial health and adherence to antiretroviral therapy (ART), but existing insights suffer from methodological limitations. We explored disclosure over time during pregnancy and postpartum among 1347 HIV-positive women in Cape Town. Among 995 women diagnosed HIV-positive before the pregnancy and entering antenatal care (median age 30 years), 95% had disclosed to ≥ 1 individual. In Mokken scale analysis, we observed two separate dimensions of disclosure: disclosure to a male partner, and disclosure to family/community members. Among 352 women diagnosed during the pregnancy and initiating ART (median age 27 years), 61% disclosed to a male partner and 71% to a family/community member by 12 months after diagnosis. Relationship status modified the impact of pregnancy intentions and poverty on disclosure to a male partner. These unique data provide important insights into dimensions of disclosure during pregnancy and postpartum, and suggest that women's social and economic circumstances are central determinants of disclosure.

Introduction: Alcohol use during pregnancy is prevalent in South Africa, but there are few prospectively-collected data exploring patterns of consumption among HIV-infected women, which may be important to improve maternal and child health outcomes. We examined patterns of and factors associated with alcohol use prior to and during pregnancy among HIV-infected pregnant women in Cape Town, South Africa., Methods: Participants were enrolled when entering antenatal care at a large primary care clinic, and alcohol use was assessed using the AUDIT (Alcohol Use Disorders Identification Test). In analysis, the AUDIT-C scoring was used as a measure of hazardous drinking, and we examined factors associated with patterns of alcohol use in logistic regression models., Results: Among 580 women (median age: 28.1 years), 40% reported alcohol use during the 12 months prior to pregnancy, with alcohol use characterised by binge drinking and associated with single relationship status, experience of intimate partner violence (IPV), and lower levels of HIV-related stigma. Of this group, 65% had AUDIT-C scores suggesting hazardous alcohol use, with hazardous alcohol users more likely to report having experienced IPV and having higher levels of education. Among hazardous alcohol users, 70% subsequently reported reduced levels of consumption during pregnancy. Factors independently associated with reduced consumption included earlier gestation when entering antenatal care and report of a better patient-healthcare provider relationship., Conclusions: These unique data provide important insights into alcohol use trajectories in this context, and highlight the urgent need for an increased focus on screening and intervention at primary care level., (Copyright © 2017 Elsevier B.V. All rights reserved.)

HIV-infected pregnant women in sub-Saharan Africa are at risk for depression and alcohol abuse. Young women may be more vulnerable, but little is known about the psychosocial functioning of this population. We compared younger (18-24 years old) and older (≥25 years old) HIV-infected pregnant women initiating antiretroviral therapy (ART) in Cape Town, South Africa. Women were assessed on a range of psychosocial measures, including the Alcohol Use Disorders Identification Test and the Edinburgh Postnatal Depression Scale (EPDS). Among 625 women initiating ART, 16 % reported risky alcohol use and 21 % alcohol-related harm; these percentages were similar across age groups. When younger women were stratified by age, 37 % of 18-21 years old versus 20 % of 22-24 years old reported alcohol-related harm (p = 0.02). Overall, 11 % of women had EPDS scores suggesting probable depression, and 6 % reported self-harming thoughts. Younger women reported more depressive symptoms. Report of self-harming thoughts was 11 % in younger and 4 % in older women (p = 0.002). In multivariable analysis, age remained significantly associated with depressive symptoms and report of self-harming thoughts. Level of HIV-related stigma and report of intimate partner violence modified the association between age and depressive symptoms. Young HIV-infected pregnant women in South Africa were more likely to report depressive symptoms and self-harming thoughts compared to older women, and the youngest women reported the highest levels of alcohol-related harm. HIV-related stigma and intimate partner violence may be moderating factors. These findings have implications for maternal and infant health, underscoring the urgent need for effective targeted interventions in this vulnerable population.

Depression, HIV-related stigma and low levels of social support may be particularly prevalent and adversely affect health and treatment outcomes among HIV-infected pregnant women. We examined factors associated with social support and stigma among pregnant women initiating antiretroviral therapy in the Western Cape, South Africa; and explored associations with depressive symptoms (Edinburgh Postnatal Depression Scale; EPDS) in linear regression models. Among 623 participants, 11 and 19 % had elevated EPDS scores using thresholds described in the original development of the scale (scores ≥13 and ≥10, respectively). Social support and stigma were highly interrelated and were associated with depressive symptoms. Stigma was observed to moderate the association between social support and depression scores; when levels of stigma were high, no association between social support and depression scores was observed. Elevated depression scores are prevalent in this setting, and interventions to reduce stigma and to address risk factors for depressive symptoms are needed.

Objectives: Intimate partner violence (IPV) during pregnancy may be common in settings where HIV is prevalent but there are few data on IPV in populations of HIV-infected pregnant women in Southern Africa. We examined the prevalence and correlates of IPV among HIV-infected pregnant women., Setting: A primary care antenatal clinic in Cape Town, South Africa., Participants: 623 consecutive HIV-infected pregnant women initiating lifelong antiretroviral therapy., Measures: IPV, depression, substance use and psychological distress were assessed using the 13-item WHO Violence Against Women questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), Alcohol and Drug Use Disorders Identification Tests (AUDIT/DUDIT) and the Kessler 10 (K-10) scale, respectively., Results: The median age in the sample was 28 years, 97% of women reported being in a relationship, and 70% of women reported not discussing and/or agreeing on pregnancy intentions before conception. 21% of women (n=132) reported experiencing ≥1 act of IPV in the past 12 months, including emotional (15%), physical (15%) and sexual violence (2%). Of those reporting any IPV (n=132), 48% reported experiencing 2 or more types. Emotional and physical violence was most prevalent among women aged 18-24 years, while sexual violence was most commonly reported among women aged 25-29 years. Reported IPV was less likely among married women, and women who experienced IPV were more likely to score above threshold for substance use, depression and psychological distress. In addition, women who reported not discussing and/or not agreeing on pregnancy intentions with their partner prior to conception were significantly more likely to experience violence., Conclusions: HIV-infected pregnant women in the study reported experiencing multiple forms of IPV. While the impact of IPV on maternal and child health outcomes in the context of HIV infection requires further research attention, IPV screening and support services should be considered within the package of routine care for HIV-infected pregnant women., Trial Registration Number: NCT01933477., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Critical to conducting high quality research is the ability to attract and retain participants, especially for longitudinal studies. Understanding participant experiences and motivators or barriers to participating in clinical research is crucial. There are limited data on healthy participant experiences in longitudinal research, particularly in low- and middle-income countries. This study aims to investigate quantitatively participant experiences in a South African birth cohort study., Methods: Maternal participant experience was evaluated by a self-administered survey in the Drakenstein Child Health Study, a longitudinal birth cohort study investigating the early life determinants of child health. Pregnant mothers, enrolled during the second trimester, were followed through childbirth and the early childhood years. Satisfaction scores were derived from the participant experience survey and quantitatively analyzed; associations between satisfaction scores and sociodemographic variables were then investigated using a linear regression model., Results: Data were included from 585 pregnant mothers (median age 26.6 years), who had participated in the study for a median time of 16 months. Overall participant satisfaction was high (median score 51/60) and associated with increased attendance of study visits. Reasons for participating were a belief that involvement would improve their health, their child's health or the health of family and friends. Potential reasons for leaving the study were inconvenience, not receiving clinical or study results, and unexpected changes in study visits or procedures. Variables associated with higher overall satisfaction scores were no prior participation in research, higher socioeconomic status, less intensive follow-up schedules and having experienced stressful life events in the past year., Conclusions: Satisfaction scores were high and associated with increased visit attendance. Participants' perceived benefits of study participation, most notably the potential for an improvement in the health of their child, were a significant motivator to enroll and remain in the study. The consistent theme of perceived health benefits as a motivator to join and remain in the study raises the question of whether participation in research results in actual improvements in health.

Background: Maternal antenatal depression may be particularly prevalent in low- and middle-income countries, but there is a paucity of data on its effect on birth outcomes in such settings. We investigated risk factors for antenatal depression and the associations between depression and infant birth outcomes in the Drakenstein Child Health Study (DCHS), a birth cohort study in the Western Cape, South Africa., Methods: The prevalence of depression in pregnant women enrolled in the DCHS from primary care antenatal clinics was measured using the Beck Depression Inventory (BDI-II). Predictors of antenatal depression were investigated using logistic regression, and the associations between depression and infant birth outcomes were examined in linear regression models., Results: Among 726 pregnant women (median age: 26 years), 156 (21%) had BDI-II scores suggesting depression. Independent predictors of depression included single marital status, low socioeconomic status (SES), recent stressful life events, unplanned pregnancy, childhood trauma, and past-year intimate partner violence. No association was observed between antenatal depression and preterm birth. Strong associations were observed between antenatal depression and decreased infant weight-for-age (WAZ) and head circumference-for-age (HCAZ) z-scores at birth. In multivariable analysis, the association between depression and decreased HCAZ remained significant, when adjusted for clinic, SES, and recent stressful life events., Conclusions: Antenatal depression and associated risk factors are highly prevalent in this setting and are associated with adverse fetal growth. Maternal mental health may be an important predictor of infant growth in utero., (© 2015 John Wiley & Sons Ltd.)

Male partner involvement (MPI) has been identified as a priority intervention in programmes for the prevention of mother-to-child transmission (PMTCT) of HIV, but rates of MPI remain low worldwide. This study used a quantitative survey (n=170) and two focus group discussions (FGDs) with 16 HIV-positive pregnant women attending a public sector antenatal care service in Khayelitsha, South Africa, to examine the determinants of high levels of involvement and generate a broader understanding of women's experiences of MPI during pregnancy. Among survey participants, 74% had disclosed their status to their partner, and most reported high levels of communication around HIV testing and preventing partner transmission, as well as high levels of MPI. High MPI was significantly more likely among women who were cohabiting with their partner; who had reportedly disclosed their HIV status to their partner; and who reported higher levels of HIV-related communication with their partner. FGD participants discussed a range of ways in which partners can be supportive during pregnancy, not limited to male attendance of antenatal care. MPI appears to be a feasible intervention in this context, and MPI interventions should aim to encourage male partner attendance of antenatal care as well as greater involvement in pregnancy more generally. Interventions that target communication are needed to facilitate HIV-related communication and disclosure within couples. MPI should remain a priority intervention in PMTCT programmes, and increased efforts should be made to promote MPI in PMTCT.

In settings with a high burden of HIV, pregnant women often experience a cluster of risk factors, including alcohol use and intimate partner violence (IPV). These interrelated risks are poorly understood among pregnant women at risk of HIV in sub-Saharan Africa. We aim to determine cross-sectional associations between pregnant women's alcohol use and victimization due to IPV in the HIV-Unexposed-Uninfected Mother-Infant Cohort Study in Cape Town, South Africa. Women who tested HIV-negative at first antenatal care (ANC) visit were followed to delivery. Trained interviewers collected demographic and psychosocial information, including recent alcohol use and experiences of IPV victimization. We assess the prevalence of alcohol use and associations with IPV using multivariable logistic regression. In 406 HIV-uninfected pregnant women (mean age = 28 years; mean gestational age = 21 weeks), 41 (10%) reported alcohol consumption in the past 12 months; 30/41 (73%) of these at hazardous levels. Any and hazardous alcohol use were associated with greater odds of reporting past year IPV (adjusted odds ratio [aOR] for hazardous use: 3.24, 95% CI = 1.11, 7.56; aOR for any alcohol use: 2.97, 95% CI = 1.19, 7.45). These data suggest the occurrence of overlapping HIV risk factors among pregnant women and may help design improved health interventions in this population.

Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor antiretroviral therapy (ART) outcomes, which may be driven partly by HIV-related stigma. We conducted in-depth interviews with 20 pregnant and postpartum WLHIV aged 19–24 years to understand how different forms of HIV-related stigma manifest in their lives, as well as their experiences of HIV-status disclosure and social support. Participants described profound levels of perceived stigma in their community, including gossip from other young women and judgement from older adults. Consequently, participants disclosed to a limited number of people to avoid being stigmatised, and disclosure to peers was especially uncommon. However, disclosure in certain situations was described as leading to emotional support and support for ART adherence, and disclosure to older WLHIV resulted in participants having a role model. Finally, participants expressed varied ways in which they accept, speak about, and live with their HIV diagnosis. These data provide a rich understanding of the experiences of HIV-related stigma in this population and point to the need for psychosocial interventions focussed on acceptance and coping with an HIV-positive diagnosis despite profound levels of perceived stigma, as well as navigating decisions around the targets and timing of disclosure. Trial registration: ClinicalTrials.gov identifier: NCT04036851. [ABSTRACT FROM AUTHOR]

Perinatal alcohol use is common in South Africa, including among young women living with HIV (WLHIV), but there are few insights into the drivers of alcohol use in this population. Following the completion of a pilot trial of a peer support intervention for WLHIV aged 16–24 years in Cape Town, we purposively selected participants who had reported perinatal alcohol use at ≥1 study visits to complete a qualitative in-depth interview exploring their experiences of substance use. Of 119 women enrolled, 28 reported alcohol use, and 24 were interviewed, with ≥1/3 reporting drinking throughout their pregnancy. Women described living in a community where heavy perinatal alcohol consumption is normalised, including among their peers, leading to social pressure. Despite being aware of the risks of perinatal alcohol use, women described a disconnect between public health messaging and their experiences. Although most acknowledged the negative effects of alcohol in their lives, self-efficacy to reduce consumption was diminished by peer influences and the lack of formal employment and opportunities for recreation. These findings provide insights into the drivers of perinatal alcohol use in this setting, and suggest that without meaningful community-level changes, including employment opportunities and alternatives for socialising, interventions may have limited impact. [ABSTRACT FROM AUTHOR]

In settings with a high burden of HIV, pregnant women often experience a cluster of risk factors, including alcohol use and intimate partner violence (IPV). These interrelated risks are poorly understood among pregnant women at risk of HIV in sub-Saharan Africa. We aim to determine cross-sectional associations between pregnant women's alcohol use and victimization due to IPV in the HIV-Unexposed-Uninfected Mother-Infant Cohort Study in Cape Town, South Africa. Women who tested HIV-negative at first antenatal care (ANC) visit were followed to delivery. Trained interviewers collected demographic and psychosocial information, including recent alcohol use and experiences of IPV victimization. We assess the prevalence of alcohol use and associations with IPV using multivariable logistic regression. In 406 HIV-uninfected pregnant women (mean age = 28 years; mean gestational age = 21 weeks), 41 (10%) reported alcohol consumption in the past 12 months; 30/41 (73%) of these at hazardous levels. Any and hazardous alcohol use were associated with greater odds of reporting past year IPV (adjusted odds ratio [aOR] for hazardous use: 3.24, 95% CI = 1.11, 7.56; aOR for any alcohol use: 2.97, 95% CI = 1.19, 7.45). These data suggest the occurrence of overlapping HIV risk factors among pregnant women and may help design improved health interventions in this population. [ABSTRACT FROM AUTHOR]

In South Africa, up to 40% of pregnant women are living with human immunodeficiency virus (HIV), and 30–45% are obese. However, little is known about the dual burden of HIV and obesity in the postpartum period. In a cohort of HIV‐uninfected and HIV‐infected pregnant women initiating antiretroviral therapy in Cape Town, South Africa, we examined maternal anthropometry (weight and body mass index [BMI]) from 6 weeks through 12 months postpartum. Using multinomial logistic regression, we estimated associations between baseline sociodemographic, clinical, behavioural, and HIV factors and being overweight–obese I (BMI 25 to <35), or obese II‐III (BMI >35), compared with being underweight or normal weight (BMI <25), at 12 months postpartum. Among 877 women, we estimated that 43% of HIV‐infected women and 51% of HIV‐uninfected women were obese I‐III at enrollment into antenatal care, and 51% of women were obese I‐III by 12 months postpartum. On average, both HIV‐infected and HIV‐uninfected women gained, rather than lost, weight between 6 weeks and 12 months postpartum, but HIV‐uninfected women gained more weight (3.3 kg vs. 1.7 kg). Women who were obese I‐III pre‐pregnancy were more likely to gain weight postpartum. In multivariable analyses, HIV‐infection status, being married/cohabitating, higher gravidity, and high blood pressure were independently associated with being obese II‐III at 12 months postpartum. Obesity during pregnancy is a growing public health concern in low‐ and middle‐income countries, including South Africa. Additional research to understand how obesity and HIV infection affect maternal and child health outcomes is urgently needed. [ABSTRACT FROM AUTHOR]

Supporting the ability of women living with HIV (WLWH) to avoid unintended pregnancy during the postpartum period decreases the number of new pediatric HIV infections, reduces pregnancy-related morbidity and mortality, and is a cost-effective strategy for the elimination of mother-to-child transmission. However, little is currently known about the contraceptive intentions and experiences of reinitiating family planning use among mothers living with HIV as they transition from pregnancy into postpartum. To (1) understand the contraceptive trajectories of women living with HIV during pregnancy and postpartum in Cape Town, South Africa, and (2) identify factors shaping differing contraceptive trajectories during the postpartum period. Thirty pregnant WLWH were interviewed during their eighth month of pregnancy and completed follow-up interviews at 6–8 weeks and 9–12 months postpartum (n = 81 total interviews). Interview topics included postpartum contraception intentions, contraceptive use, and experiences accessing family planning services. Trajectory analysis of contraceptive intentions was applied after initial thematic coding. While nearly half of women interviewed during pregnancy expressed an intention to utilize a non-injectable contraceptive option after childbirth (e.g. implant, IUD, sterilization, oral contraceptive pills), all women interviewed at one year postpartum had received at least one injection. Three main contraceptive trajectories were identified. (1) realization of contraceptive intentions postpartum; (2) unrealized contraceptive intentions postpartum; and (3) change in contraceptive intention over time. Provider influence, coordination of services, and low contraceptive inventory were identified as potential factors shaping the contraceptive trajectories of participants enrolled in the study. Disparities between contraceptive method intentions articulated by WLWH during pregnancy and methods attained postpartum suggest that significant barriers remain for women who are unsatisfied with injectable contraception. Failing to provide postpartum mothers living with HIV their intended family planning method undermines efforts to prevent unintended pregnancy, a key pillar of elimination of mother-to-child transmission. • Contraceptive intentions of pregnant women living with HIV were traced postpartum. • A trajectory approach was used to analyze longitudinal qualitative data. • All women received the injection postpartum, regardless of their method intention. • Provider influence, care coordination, and inventory impacted method trajectories. [ABSTRACT FROM AUTHOR]